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We are grateful to Colleti Junior et al (1) for their interest on our recently published article in Pediatric Critical Care Medicine (2), and we would like to provide some further comments in this regard.
No mechanical ventilation (MV) weaning protocol is applied in our unit, as there is limited evidence that implementation of such a protocol would reduce the duration of the MV (3). In our study, the decision to extubate was at the discretion of the attending physician, albeit only if the following criteria were met: hemodynamic stability, a normal state of consciousness, spontaneous breathing, low pressure support, and FIO2 (i.e., lower than 40%), with manageable secretions. However, we agree with Drs. Colleti Jr and Brunow de Carvalho (1) that although nurses are involved in the sedation, they are not engaged in the weaning process, and that they cannot identify readiness for extubation. A child becoming restless and distressed will tend to make the nurses less likely to comply with the protocol. There is hence merit in improving the education of healthcare teams, particularly in terms of the adverse effects of oversedation and the importance of adequate sedation.
Regarding the issue of the use of dexmedetomidine, this drug was not used in our unit during this study. We nonetheless agree with Drs. Colleti Jr and Brunow de Carvalho (1) that the use of dexmedetomidine may facilitate extubation in some children, particularly those who are intolerant of intubation in the awake state, and it could reduce oversedation and the duration of MV (4). In critically ill adults, dexmedetomidine may be effective at reducing the duration of MV (5). Additional randomized clinical trials are necessary however with critically ill children. Furthermore, several studies have reported adverse effects from midazolam. Associations between benzodiazepines and withdrawal syndrome or delirium have been documented, as detailed in our article. Although dexmedetomidine may decrease these adverse effects, clinical trials are needed to confirm these results.
In regard to the proportion of nurses per patient, the results would probably have been different with a ratio of 1:1. Indeed, nurses tend to exhibit a degree of reluctance when it comes to decreasing sedatives, as they are more focused on patient safety than on reducing the duration of MV. One reason for this reluctance may stem from the fact that nurses are not always present in the patient’s room since, in keeping with what is recommended in France, the proportion of nurses to patients is still 1:2. Training in the use of the protocol was carried out during the 6-month interval between the two phases. Briefings by the interprofessional team were organized, and the two physicians and the nurses who collaborated on the elaboration of the protocol assisted with its implementation in the unit. Furthermore, we received very positive feedback from nurses and doctors regarding the implementation of our protocol. However, a recent study underscores the difficulty of maintaining the effects of the protocol over time. This study showed that the outcomes were worse a few years following the implementation of a sedation PICU protocol, when compared with the outcomes immediately after the implementation (6). We believe that education of the healthcare team must be a continuous process in order to improve sedative drug use, and that a nurse-driven sedation protocol, associated with weaning protocols and a suitable choice of sedative drugs may be a way to decrease the duration of ventilation.

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